3 Nursing 2030 Vision

This chapter describes the Nursing 2030 Vision, setting out
where the nursing community in Scotland is currently and where we
are going as we move towards 2030.

Three key themes have emerged for the Vision:

personalising care

preparing nurses for future needs and roles

supporting nurses.

The themes have arisen from the work of the engagement process,
the direction of travel for health and social care policy in
Scotland, and national and international evidence. While they by no
means represent the whole picture on what needs to happen to
nursing as we move towards 2030, they help to focus our thinking as
we set out the Vision to prepare nurses to meet the population's
needs now and in the future.

Actions around the themes will be taken forward through our
action plan, with national oversight.

Personalising Care

Personalised care is about providers and recipients of care
being equal partners. It is about moving away from the notion of
nurses 'doing for' people towards the idea of 'working with'
people, finding out what is important to them then using all their
skills and experience to help them achieve their
goals.

Personalised care calls for high degrees of technical and
professional competence, but also the ability to understand what
people are communicating, identify sources and resources locally
and further afield that might help, work across professions and
agencies in common cause, and ensure that the system works to the
needs of the person, and not the other way round.

Promoting caring and compassion

The importance of caring and compassion in nursing has been
stated many times. We make no apology for re-stating it here.

The engagement process for the Vision revealed that nurses,
students and stakeholders hold care, professionalism and compassion
in high esteem. Compassion, in particular, is considered a
fundamental attribute of high-quality, personalised, rights-based
care that maintains and protects patients' dignity, autonomy and
choice. When combined with technical competence, critical thinking
and decision-making skills, compassion provides the power behind
the attitudes, values and behaviours that typify personalised care
at its best.

Care and compassion are easy to see in practice, but difficult
to define in words. What is clear, though, is that they mean
different things to different people - what may seem caring and
compassionate to one person might seem patronising or even
intrusive to another.

Care and compassion, as with all things in nursing, should be
tailored to the needs of the person. This will be the cornerstone
of nursing as we travel towards 2030 -
a personalised, rights-based service embedded within a
caring and compassionate professional relationship with individuals
and communities.

As we move towards 2030, all nurses will be practising to this
ethos, working with patients and communities across the
life-course, supporting them to make the decisions to enable them
to live longer, healthier lives, helping them through periods of
acute ill health or to manage long-term conditions, tackling social
isolation and supporting people to engage with their communities in
ways that are meaningful to them, and preparing them for a peaceful
and dignified death.

It is characterised by an understanding that people are the
focus and beneficiaries of all nursing endeavour, and that nurses
are willing to advocate on their behalf to promote and protect
their health and wellbeing. And it reflects a long-held nursing
approach that focuses not only on the immediate perceived problem,
but also takes into account the person's wider physical,
psychological, social, family and community life to make a real and
lasting difference to their health and wellbeing.

Taking technology-enabled care forward

This approach will be enhanced, but not replaced, by the use of
technology, both existing and still to be developed.

It seems likely that as we move towards 2030, the impact of
technology on health and social care will be growing. Many patients
may well be accessing most of their treatment programmes at home
through remote technologies, including consultations and
discussions with professionals over video links or other
communication technologies rather than face to face.

We need to ensure nurses are prepared to be comfortable in
increasingly technological environments, with the technical and
communication skills they need to support patients and enable their
self-management potential. Measures to promote nurses' competence
and confidence in this vital area of practice, including specific
activity to embed technological competence in undergraduate nursing
curricula, will be set out in our action plan.

Nursing has always responded positively to technological change,
being quick to grasp the potential technology offers to support
patients to recover and live well with their conditions. We have
seen many advances in the delivery of health and social care
through technological means in recent years, with nurses frequently
in the forefront of pioneering e-health and telehealth
initiatives.

We must be clear, though, that while technology offers a
tremendous adjunct to nursing care, it can never
replace nursing care - it can never supplant the
human relationships at the heart of nursing, or the caring and
compassionate ethos of nursing that means so much to patients,
families and communities.

Preparing Nurses for Future Needs and Roles

This is fundamental to achieving the Nursing 2030 Vision.
It is about how competent and skilled nurses can take on new ways
of working to enable them to perform in a wide range of settings
with many different colleagues and teams, while retaining a central
focus on personalised, compassionate, rights-based care. And it is
also about ensuring the right number and quality of nurses are
being prepared with the right competence and attributes to assume
their roles in the workforce with confidence.

Nursing is an incredibly wide and diverse profession that
offers many career options. It takes place in a huge range of
settings (including hospitals, care homes, people's homes, schools,
GP practices,
prisons, workplaces, and education and research institutions),
involves contributions to health, social care, independent and
voluntary services, and delivers services to people with health and
wellbeing issues affecting their physical, mental, emotional and
social status across the life-course.

This diversity and variety is likely to grow as we move
towards 2030, as people's needs and the settings and sectors in
which care is delivered evolve. Nurses will require the right
preparation, supervision and support to be confident in taking
advantage of the transformed roles that will be in place, and will
need to be educated and prepared in the right numbers to meet
population needs.

Securing nurses for the future

There is a clear and consistent message developing from current
research that when registered nurse staffing levels fall, patient
safety and outcomes decrease, and patient mortality increases.
[3] A number of measures are in place to secure the current and
future nursing workforce in Scotland, including our ongoing
commitment to supporting and expanding the graduate workforce and
retaining existing nurses across the health and care sectors. At
the time of writing, the Health (Staffing Levels) Scotland Bill
[4] was undergoing national consultation.

Scotland has seen successive increases in student nurse intakes
in recent years. This is a very healthy situation that demonstrates
nursing's attraction as a career option and augurs well for
ensuring a future nursing workforce for Scotland to meet population
needs. Small decreases in applications for undergraduate nursing
programmes have been seen recently, however, particularly among
men. The decrease is much smaller in Scotland than in other
comparable countries, but is nevertheless concerning.

We know that nursing programmes are competing against many other
attractive options for students who have the aspiration and
aptitude to pursue nursing careers. So we need to take action now
to ensure there are no detrimental repercussions for future nurse
staffing levels.

A review into widening access to nursing education and careers
has been launched in Scotland as part of this Vision to identify
best practice and barriers to entering the profession. The
Commission's recommendations will play a big part in determining
approaches to maintaining and improving access - and consequently
ensuring an ongoing and sustainable supply of nurses - as we move
towards 2030.

The engagement process for developing the Vision suggested that
some potential recruits to nursing may be harbouring false or
outdated notions of what being a nurse means. They perhaps do not
fully realise the extent of the role, the diversity of activity
that constitutes nursing, and the vast range of settings in which
nursing takes place.

Nor, perhaps, do they fully understand the academic rigour of
nursing programmes, the unique opportunities offered by clinical
placements to gain competence in nursing in different environments
and with different patient groups, or the academic, professional
and personal support offered by university and clinical staff.

They may not even realise that the bursary system for nursing
students is being retained in Scotland, alongside other measures
that help us attract and retain high-calibre students from across
society who reflect Scotland's cultural and socioeconomic
diversity.

Efforts are needed to modernise the public's perceptions of
nursing - who nurses are, what they do and where they work. This
will not only help to ensure the public is fully informed about,
and engaged with, the benefits nurses can bring them, but also
highlight the attractiveness of nursing as a career to potential
students and, indeed, nurses who have not been practising for some
time but would be interested in re-entering the profession. This is
an area that will be explored further with stakeholders with a view
to setting out concrete actions.

As we move forward, we also need to ensure nurses are educated
about, and skilled in, recognising issues around nurse staffing
levels and presenting evidence-based cases to ensure we have the
right number of staff.

Working differently

It is vital that we continue to take steps to ensure nurses are
prepared to provide the flexible and effective responses the
population needs now and in the future. We do this by looking at
the roles nurses currently perform and modernising them for the
next decade and beyond.

Work on this has already started through, for example, the
Transforming Roles programme, which aims to
provide strategic oversight, direction and governance to:

develop and transform roles to meet the current and future
needs of Scotland's health and care system

It involves nurses not only working in different settings with
different teams, but also working in different ways - being
prepared to break down rigid role demarcations to benefit their
patients, working in genuine partnerships with informal carers, the
voluntary sector and others, providing services wherever people and
communities can be accessed, and embracing the challenges of a
dynamic and shifting health and social care environment with
flexibility and imagination.

Our efforts through Transforming Roles and other initiatives are
aimed at ensuring nurses have the right educational and personal
support to enable them to assume these transformed roles with
confidence and competence.

The new standards for nursing education, to be published by the
Nursing & Midwifery Council in 2018, seem likely to propose a
shift in expectations of what registrants can deliver. We must
remain agile in responding to the standards and ensure they are
reflected in how students are prepared for work as registered
nurses.

Promoting health and wellbeing, and tackling
inequalities

'Traditional' perceptions of nursing, which depict nurses as
being focused primarily on ill health, working with others to
'sort' the immediate problem without regard to what caused it in
the first place and what factors make it likely to recur in the
future, are long out of date.

Nursing today still has a focus on supporting people through
periods of acute ill health in hospital and in the community. But
more and more it is also about prevention, addressing wider issues
around promoting health and wellbeing, tackling complex social
circumstances that have resulted in persistent health inequalities,
and working to ensure parity of esteem between physical and mental
health care.

Providing nursing care is about much more than dealing with the
acute episode. The unique relationship between nurses and those
they care for enables nurses to see people in the round, how they
live their lives, the environments in which they live, the
lifestyle elements that might be supporting or harming their
health, and the obstacles they face as individuals and communities
in accessing the factors that promote health and wellbeing. Nurses'
proximity to people and the places in which they live, work, study
and socialise puts them in a prime position to make a real impact
in this area.

Informed, engaged and committed nurses throughout the country
are working with individuals and communities to tackle the issues
that harm health and wellbeing and advocating for change in social
and economic structures to enhance people's chances of living
healthier lives. They are developing sensitivities to issues such
as stigma and discrimination and working with voluntary groups and
others to challenge it whenever and wherever it emerges.

This focus will become more commonly embedded in nursing
practice as we move towards 2030, because the evidence of nursing
having impacts in these areas, which are so important to the people
of Scotland now and in the future, is growing. Nurses working with
people with learning disabilities provide a particular example,
leading the way in showing how efforts to promote health and
wellbeing and tackle inequalities make real differences to people's
lives. As a profession, we need to recognise, refine and reinforce
our contribution in these areas more explicitly, gathering evidence
of impact and developing our offer to improve people's outcomes and
experiences.

Enhancing leadership

Nurses are already leading many national and local initiatives
at strategic and operational levels. This will increase as we move
towards 2030. More and more, nurses will be taking the lead on:

national initiatives, influencing and driving
transformational change in the way services are designed and
delivered

local-level service redesign, working with
communities and partners to make things better for the
population

individual episodes and packages of care,
working with others to assess people's needs, make plans, deliver
or supervise care delivery, and evaluate outcomes.

The last of these points - nurses leading on individual episodes
and packages of care - has particular relevance for nurses and the
population.

It is much more likely as we move through the next decade that
for some patients, entire episodes of care, or specific elements of
care packages, will be managed by nurses and their teams. This is a
profound change not just for nurses, but also for the population,
who may be accustomed to having all aspects of their care overseen
by a doctor.

Many nurses in Scotland have been developing their roles over
recent years, acquiring skills, expertise, experience and
confidence in specific areas of practice to enable them to assess,
plan, deliver and evaluate entire episodes of care for individuals
and groups of patients. The emerging evidence suggests that not
only are patients benefiting from nurse-led services, but services
are too, with colleagues in the multidisciplinary team able to
focus their energies on specific areas of expertise as a
result.

As we saw in the
Working differently section above, work is
already underway through the Transforming Roles programme to put in
place the infrastructure to ensure nurses have the skills they will
require to meet people's needs as we move towards 2030.
Transforming Roles includes a focus on advanced nursing practice
that aims not only to develop nursing leadership for the future,
but also expand nursing practice and promote research, education
and development.

We will continue to act to ensure nurses have the right
preparation and ongoing support to assume the enhanced roles we
need for the future, and that the public understands the rationale
and benefits of nurse-led care.

Supporting Nurses

The engagement process for the Vision revealed that nurses
take great pride in what they do, but are facing challenges in
their day-to-day lives that may be hindering their
progression.

Some of these challenges are around accessing the right
education and professional development activity to prepare and
support them for their roles, and some are about maintaining their
own health and wellbeing in the face of the stressors they
experience.

This not only affects today's nurses, but may also impact
on future recruitment. As we move towards 2030, it is vital that we
identify these challenges and, wherever possible, take steps to
address them.

Encouraging education and development

All students exiting nursing pre-registration programmes in
Scotland do so with a minimum of a bachelor's degree. We are
committed to maintaining this all-graduate nursing workforce.

Some stakeholders in the engagement process questioned the need
for nurses to be graduates. It is certainly the case that
non-graduate nurses provide high standards of care. They play a key
role in the wider nursing team and are hugely valued team
members.

The evidence that having a graduate workforce leads not only to
better patient outcomes, but also to reduced patient mortality, is
nevertheless compelling.
[3] And as we move towards 2030, we expect the benefits of the
all-graduate nursing workforce in Scotland to become more and more
evident to the population.

Once graduated, nurses must have a clear and exciting career
trajectory before them, supported by the right education and
development as they progress. We have in Scotland national career
frameworks setting out the routes nurses can take to reach their
goals, and these will continue to be developed and refined to
ensure they reflect current practice and future needs.

Scotland has a vibrant nursing research community that makes a
significant contribution to generating the evidence base for
nursing practice. Research will be further supported by promoting
partnerships between practitioners and researchers to expand the
evidence base for high-quality and effective practice.

Promoting nurses' health and wellbeing

Nurses of today will have longer careers than their
predecessors. As 2030 approaches, working to age 70 before retiring
is likely to be the norm for many citizens.

Older age does not necessarily mean poorer health, but there is
a natural and gradual decrease in fitness as we age. Research into
older nurses at work shows they can struggle with the physical and
psychological demands, and that this can be exacerbated by, for
example, working patterns.
[5],
[6] While little research has been
done on the health or economic impacts of shift-working in nursing,
it has been reported that nurses working for 12 hours or longer are
more likely to report reduced efficiency and effectiveness, leading
to poor-quality care, poor patient safety and more care left
undone.
[7]

The need to put in place measures to protect and promote nurses'
physical and mental health and wellbeing therefore becomes even
more important.

We know from important research carried out in Scotland
[8] that some aspects of nurses' health and wellbeing are below
that of other health professionals and the general population. Some
are living with physical health problems, working long hours with
insufficient rest, eating an unbalanced diet and taking part in
insufficient physical activity, consequently leading to overweight
or obesity. Psychologically, the burden of caring over many years
can affect some nurses, resulting in what has been called
'compassion fatigue'. And recent reports suggest some may be facing
financial hardship, and that nurses may be more vulnerable to
domestic violence.
[9]

This is not just about nurses - all workers in health and social
care are liable to experience the physical and emotional stress
that nurses face. But it is a big issue for nursing, which commonly
involves significant levels of physical exertion and in which
prolonged direct exposure to psychologically stressful situations
may be higher than for other professions.

Evidence suggests there are direct links between poor health,
unhealthy behaviours, psychological stress and the environments in
which nurses work. Health and social care settings can be
stressful. Issues such as shift patterns affecting diet, physical
activity and sleep and, as a predominantly female profession,
nurses' caring responsibilities within their families are also
directly relevant.

All environments in which nurses work, whether in communities,
hospitals, care homes or elsewhere, are hugely influential in
fostering - or inhibiting - professional practice and behaviours.
Physical surroundings and availability of equipment and other
resources are clearly significant, but the ambience, or 'culture',
of working environments is also important.

A positive culture can support nurses to feel valued, share
their experiences and insights honestly and openly, and feel
liberated to develop their practice and careers. But a negative
culture can make nurses feel unappreciated, deny them opportunities
to have their say on matters important to them, deter them from
speaking out about care standards, and persuade them just to put
their heads down and 'get on with the job'.

The population will only reap the health and wellbeing benefits
nursing can bring them, and nurses will only experience the
opportunities their careers can offer, when nurses feel supported,
empowered, enabled and valued in their places of work.

Essentially, promoting nurses' health and wellbeing is a public
health issue with potentially serious implications for nurses,
patients and service capacity going forward. It is a complex issue
that cannot be ignored. But nor must it be addressed by
uncoordinated and precipitate action. It must be investigated
fully, involving all relevant stakeholders to identify the exact
nature of the problems and potential sustainable solutions.

As we noted above, by 2030, graduate nurses on exit from their
education programmes may be looking at careers that span 50 years
or more. Together, we need to find ways to help nurses stay
healthier and fitter for longer so they are enabled to have long,
successful and highly satisfying careers meeting the needs of the
people of Scotland.

Ensuring supervision and support

We recognise that when nurses feel valued and supported, they
are empowered to work to their maximum potential. They need the
opportunity to feel involved in their organisation(s), know what is
going on, have a say in how services are developed, and have their
views heard and respected.

That is why we have a range of mechanisms in Scotland for
gauging how staff feel, identifying how they can be further
supported, and acting on the issues they describe as important. We
must ensure these kinds of opportunities for gathering feedback and
experiences from nurses continue and expand - ultimately, the
benefits are seen in improved patient care and better staff
morale.

Experience suggests nurses who have access to one-to-one or
group supervision in the workplace derive great value. Supervision
(often (but not necessarily) called clinical supervision) provides
nurses with space to reflect on and discuss aspects of their role
that are motivating and inspiring them, and also those elements
that are frustrating or concerning them. Nurses and their
supervisors can then jointly work through how the former can be
promoted and the latter addressed. Processes in place for
developing and assessing students' practice are similarly highly
valued.

We consider supervision to be an essential part of support for
nurses. It provides them with a platform to reflect on practice,
agree new approaches and decide courses of action. It also, in a
role that can be highly emotionally intensive and calls for a great
deal of giving of self to others, provides opportunities to turn
the spotlight on the nurse and her or his needs - we know from the
engagement process how much nurses treasure that opportunity. And
the reflection triggered by supervision can prove helpful to nurses
when seeking professional revalidation with the Nursing &
Midwifery Council.

We envisage that as we move towards 2030, all nurses, regardless
of grade or setting, will be receiving supervision appropriate to
their roles. Our task now is to seek out how that aspiration can be
achieved, working in partnership with the Nursing & Midwifery
Council and others.

Demonstrating impact

We know that the vast majority of people who access nursing care
in Scotland have a good experience. But we also know that for a
few, the care they receive falls short of their expectations,
sometimes well short. That is not acceptable.

The Vision's aspiration is that everyone has a positive
experience of nursing care. All of the actions that will emerge
from the Vision will be targeted on that goal.

We need to make sure we have mechanisms in place to enable
patients and services to see the impact nursing makes, to be
reassured when standards are high, and to be able to spot quickly
when they are slipping. Such a mechanism is currently being
introduced through our
Excellence in Care framework.

Excellence in Care is about equipping
NHS boards,
clinical nursing leaders and users of services with tools to
measure and improve the impact of care across a number of areas,
from leadership, to provision of direct care, to record-keeping. It
takes into account not only hard data, but also the perceptions of
key people - patients, nurses, managers - and supports boards and
teams to assess how they are performing against some well-defined
measures to identify how they can improve quality. Excellence in
Care is therefore a mechanism for driving continuing quality
improvement in
NHSScotland.

Systems of assurance and improvement like Excellence in Care
help to ensure consistency of standards across Scotland without
losing the essence of compassionate, personalised, rights-based
care. They facilitate and empower nurses to make changes in
practice that result in improved outcomes for the people they
serve. And they help to reignite in nurses the passion for
excellence that brought them into the profession in the first
place. Our action plan will ensure such systems continue to protect
the public and inspire the profession as we move towards 2030.